Client Background Form

New Patient Details

New Client's Name

New Client's Surname

Is the client under 18 years of age?

Yes

No

Parent/Guardian Name

Client's Date of Birth

Client's Contact Number

Client's Address

Street Address

City

State

Postcode

Select the area that MouthWorks will be helping you with

Speech Therapy

Occupational Therapy

Dietetics

Music Therapy

Speech Therapy

This information will help us prepare for your first appointment with Mouthworks.

Is there a family history of speech, language or fluency(stuttering) difficulties?

Yes

No

Please provide a brief description of any family history of speech difficulties.

Are you currently seeing any other health/educational professionals? These can include Occupational Theapists, Psychologists, Paediatricians, TAS DAS, Speech Pathologists etc.

Yes

No

Is currently seeing any other health/educational professionals? These can include Occupational Theapists, Psychologists, Paediatricians, TAS DAS, Speech Pathologists etc.

Yes

No

Please list the other health/education professionals that are currently being seen.

Have you ever had a hearing test?

Yes

No

Has had a hearing test?

Yes

No

What was the outcome of the hearing test?

Does have any trouble with eating, drinking or swallowing?

Yes

No

Do you have any trouble with eating, drinking or swallowing?

Yes

No

Please describe any issues with eating, drinking or swallowing

Does take any medications or supplements?

Yes

No

Do you take any medications or supplements?

Yes

No

Please list any supplements or medications that are currently being taken.

Occupational Therapy

Please list any diagnosis given by other health care professionals.

Is currently taking any medications?

Yes

No

Are you currently taking any medications or supplements?

Yes

No

Please list any supplements or medications that are currently being taken.

Have you had any significant adverse experiences? These can include hospitalisations, bullying, trauma etc.

Yes

No

Has had any significant adverse experiences? These can include hospitalisations, bullying, trauma etc.

Yes

No

Please describe the adverse experiences here:

Please list any other Health Care Professionals currently involved.

Dietetics

Why are you coming coming to see us?

Why is coming coming to see us?

I can bring my recent blood test results to my appointment.

Yes

No

I can bring 's recent blood test results to my appointment.

Yes

No

What is your weight history?

What is 's weight history?

Does take any medications or supplements?

Yes

No

Do you take any medications or supplements?

Yes

No

Please list any supplements or medications that are currently being taken.

Please list any relevant medical conditions.

Is there a family history of any significant medical issues? For example: Diabetes, Heart Disease, Cancer, Food Allergies etc.

Yes

No

Please describe your family medical history.

Do you ever experience...(tick all that apply)

Reflux

Nausea

Constipation

Diarrhoea

Does ever experience... (tick all that apply)

Reflux

Nausea

Constipation

Diarrhoea

How would you describe your appetite?

How would you describe 's appetite?

Music Therapy

Where did you hear about Music Therapy?

What do you most want your child to gain from attending music therapy? Tick all that apply.

Improved communication skills

Improved social skills

Confidence

Reduced anxiety

Emotional regulation

Improved attention span and focus

Improved impulse control

Improved motor skills

Academic goals

Please list any other goals that you want to achieve through music therapy.

Does your child have any particular song preferences?

Yes

No

Please list your child's song preferences here:

Have you noticed that your child responds (positively or negatively) to different genres/types of music? E.g. loud, fast, rock, classical, etc?

Yes

No

Please describe the type of music your child responds to and how they respond.

Does your child play any instruments or enjoy experimenting with any instruments at home or in a class?

Yes

No

What instrument(s) does your child play/enjoy experimenting with?

What motivates your child or bings them joy?

Do you use any communication aids with your child? For example: visuals, schedules, AAC devices.

Yes

No

Please tell us about the communication aids you use with your child.

Are there any precautions we should take when working with your child? For example: Sensory triggers, aggressive behaviour etc.

Yes

No

Tell us about any precautions we should take when working with your child.

Extra Information & Consent

Please provide any reports, assessment, test results or any other documentation you have which may help us.

Choose File

Is there anything else that you feel might be helpful for us to know to prepare for your visit with MouthWorks?

I acknowledge that I am responsible for all fees and charges that I incur whilst receiving treatment at MouthWorks. I understand that all fees are payable on the day of consultation. I have read and agree to the Mouthworks Terms and Conditions and Privacy Policy

I acknowledge that I am responsible for all fees and charges that my child incurs whilst receiving treatment at MouthWorks. I understand that all fees are payable on the day of consultation. I have read and agree to the Mouthworks Terms and Conditions and Privacy Policy

Day	hours
Mon - Wed	8am - 6pm
Thur & Fri	8am - 5pm

Completing this form will provide us will all the details necessary to get started.

New Patient Details

Speech Therapy

Occupational Therapy

Dietetics

Music Therapy

Extra Information & Consent